Transcript Chapter 9

2
Chapter 9
Airway Management
and Ventilation
3
Objectives (1 of 27)
• 1.6.11
Describe the anatomy of the following: upper
airway, tongue, hypopharynx, nasopharynx, oropharynx,
larynx, vocal cords.
• 1.6.12
Describe the function of the vocal cords.
• 1.6.13
Describe the flow of air from outside the body
into the trachea.
4
Objectives (2 of 27)
• 1.6.14
Describe the reasons for and mechanisms of
humidification and warming of the air as it passes
through the naso- and oral pharynx.
• 1.6.15
Describe the pathological conditions that can
occur in the nose, pharynx, and larynx to obstruct or
retard air flow and identify the complications of laryngeal
fracture.
• 1.6.16
Describe the methods of airway
management.
5
Objectives (3 of 27)
• 1.6.17
Describe the methods and management of
an obstructed airway.
• 1.6.18
Describe the mechanical methods of airway
management including the benefits and limitations. Oral,
nasal and EOA.
• 1.6.19
Describe how the cervical spine is protected
throughout these maneuvers.
6
Objectives (4 of 27)
• 1.6.20
Describe the anatomy of the following:
– Lungs
– Trachea
– Alveolus
– Diaphragm
– Thoracic wall
– Pleural space
• 1.6.21
Describe how pulmonary ventilation
(inhalation and exhalation) is accomplished.
7
Objectives (5 of 27)
• 1.6.22
Describe the gaseous exchange across the
alveoli-capillary membrane (O2 and CO2.).
• 1.6.23
Describe the pulmonary problems that can
complicate exhalation and inhalation, the mechanisms
by which they reduce ventilation and management of
each problem, including:
– Open pneumothorax
– Diaphragmatic injury
– Closed pneumothorax (simple and tension)
– Flail chest.
8
Objectives (6 of 27)
• 1.6.24
Describe the problems of ventilation.
• 1.6.25
Define mouth-to-mask ventilation, its benefits
and limitations.
• 1.6.26
Discuss the bag-valve-mask (BVM), its
benefits and limitations.
• 1.6.27
Discuss the techniques for evaluating the
effectiveness of ventilation.
• 1.6.32
Discuss ventilation with an EOA.
9
Objectives (7 of 27)
• *1.6.33
Discuss ventilation with an endotracheal
tube.
• *1.6.34
Describe the equipment and method of
suctioning the airway, pharynx, and endotracheal tube.
• S1.6.60 Demonstrate effective mouth-to-mask
ventilation.
• S1.6.61 Demonstrate effective bag-valve:
– Mask
– EOA
– *ET
10
Objectives (8 of 27)
• S1.6.63 Demonstrate the manual methods of airway
management.
• S1.6.64 Demonstrate the methods of management of
an obstructed airway.
• S1.6.65 Demonstrate the mechanical methods of
airway management:
– Nasal
– Oral
– EOA
– *ET
11
Objectives (9 of 27)
• S1.6.67 Demonstrate the use of various types of
portable and fixed suction devices.
• 1.7.1
Describe the anatomy of the following: upper
airway, tongue, hypopharynx, nasopharynx, oropharynx,
larynx, and vocal cords.
12
Objectives (10 of 27)
• 1.7.2
Describe the relationship between:
– Cords and larynx
– Esophagus and larynx
– Epiglottis and larynx
– Tongue and larynx
– True cords and false cords
– Pharynx and larynx
• 1.7.3
Given a list of arterial oxygen concentrations,
the student should be able to select the normal PO2, for
a young adult breathing air.
13
Objectives (11 of 27)
• 1.7.4
Given a list of arterial carbon dioxide
concentrations, the student should be able to select the
normal PCO2.
• 1.7.5
Given an increase in arterial PCO2, the
student should be able to name this condition and
describe its effect on respiratory activity and on blood
pH in the normal individual.
14
Objectives (12 of 27)
• 1.7.6
Given a decrease in arterial PO2, the student
should be able to name this condition and describe its
effect on respiratory activity in the normal individual.
• 1.7.7
Given an increase in CO2 production, the
student should be able to list at least two ways in which
this increase may occur.
• 1.7.8
Given an increase in CO2 elimination, the
student should be able to describe how this elimination
can occur.
15
Objectives (13 of 27)
• 1.7.9
Given a list of statements, the student should
be able to identify the statement that best describes the
purpose of suctioning a patient.
• 1.7.10
Given a diagram of a piston-powered suction
unit, the student should be able to label and describe
the operation and cleaning of each component and
attached part.
16
Objectives (14 of 27)
• 1.7.11
Given that there are various types of suction
units, the student should be able to list at least four
different types of units determined by the method in
which the suction effect is obtained.
• 1.7.12
Given that there are various types of suction
catheters, the student should be able to list at least
three different types, determined by difference in use
and material composition.
17
Objectives (15 of 27)
• 1.7.13 Given a list of situations describing patients
who require suctioning, the student should indicate
which type of catheter should be used.
• 1.7.14 Given a list of statements, the student should
be able to identify the statement that best describes the
purpose of using the esophageal obturator airway.
18
Objectives (16 of 27)
• 1.7.15 Given a list of situations describing patients
with airway maintenance problems or potential airway
maintenance problems, the student should be able to
identify situations in which the use of the esophageal
obturator airway is indicated and contraindicated.
• 1.7.16 Given a list of situations, the student should be
able to identify those situations in which the esophageal
airway may be removed.
19
Objectives (17 of 27)
• 1.7.17 Given a list of advantages, the student should
be able to identify the advantages of using the
esophageal obturator airway over other methods of
airway control.
• 1.7.18
Given a list of airway adjuncts, advantages,
and disadvantages, the student should be able to match
the airway adjuncts with the advantages and
disadvantages.
20
Objectives (18 of 27)
• S1.7.19 Given an adult manikin, oropharyngeal and
nasopharyngeal airways, pocket mask, oxygen cylinder,
and bag-valve-mask, the student should be able to
demonstrate the procedure for administering intermittent
positive pressure ventilation using:
– Pocket mask
– Bag-valve-mask and oropharyngeal airway
– Bag-valve-mask with oxygen
– Nasopharyngeal airway with bag-valve-mask
21
Objectives (19 of 27)
• S1.7.20 Given a bag-valve-mask, the student should
be able to demonstrate the assembly, disassembly, and
cleaning of the bag-valve-mask unit.
• S1.7.21 Given an adult manikin, an oropharyngeal
airway, and a demand-valve unit, the student should be
able to demonstrate the procedure for performing
intermittent positive pressure ventilation.
22
Objectives (20 of 27)
• S1.7.22 Given a demand-valve unit, the student
should be able to demonstrate the assembly,
disassembly, and cleaning of the unit.
• 1.7.23 Given a list of disadvantages, the student
should be able to identify the disadvantages of using the
esophageal obturator airway over other methods of
airway control.
23
Objectives (21 of 27)
• 1.7.24 Given a diagram of the esophageal obturator
airway, the student should be able to label and describe
the function of all component parts.
• 1.7.25 Given a list of equipment and materials, the
student should be able to identify those items that must
be available before esophageal obturation is begun.
24
Objectives (22 of 27)
• 1.7.26 Given that a patient requires an esophageal
obturator airway, the student should be able to list the
procedures for insertion of the esophageal airway,
including all steps in the proper sequence.
• 1.7.27 Given a list of errors, the student should be
able to identify common errors involved in the use of the
esophageal obturator airway.
• *1.7.28
Describe laryngoscope, suction,
endotracheal tube, and bag-valve-mask.
25
Objectives (23 of 27)
• *1.7.29
Discuss indications and contraindications of
endotracheal intubation.
• *1.7.30
Discuss alternatives to endotracheal
intubation.
• *1.7.31
Discuss skill deterioration and methods of
prevention.
• *1.7.32
Discuss need for rapid placement of the ET
tube.
• *1.7.33
Discuss methods of assuring and maintaining
correct placement of the ET tube.
26
Objectives (24 of 27)
• *1.7.34
Given that a patient needs suctioning and
already has an endotracheal tube in place, the student
should be able to describe the difference between
endotracheal suctioning and oropharyngeal suctioning,
including:
– Dangers
– Precautions
27
Objectives (25 of 27)
• *S1.7.35 Given an adult intubation manikin, an
esophageal obturator airway, 30cc syringe, and a bagvalve unit, the student should be able to demonstrate
the technique for the insertion of an esophageal airway.
He should further be able to demonstrate endotracheal
intubation with the esophageal obturator in place and
subsequent correct removal of the obturator.
• *S1.7.36 Demonstrate placement of an ET within 45
seconds.
28
Objectives (26 of 27)
• *S1.7.37 Demonstrate ventilation with a bag-valve and
endotracheal tube.
• *S1.7.38 Demonstrate method by assuring and
maintaining correct placement of ET tube.
• *S1.7.39 Demonstrate reventilation for missed
intubation.
• *S1.7.40 Demonstrate skills described above both on
manikin and a live patient.
• 1.8.18 Define acid-base balance.
29
Objectives (27 of 27)
• 1.8.19 Discuss acid-base balance based on hydrogen
concentration, pH, and buffer systems.
• 1.8.20 Define and discuss the following:
– Respiratory acidosis
– Respiratory alkalosis
– Metabolic acidosis
– Metabolic alkalosis.
30
Airway
• The most important steps in patient care are obtaining
and maintaining a patent airway.
• Oxygenation of the body’s tissues occurs through the
processes of breathing and circulation.
• The primary objective of emergency care is to ensure
optimal ventilation.
• Airway maneuvers are often neglected skills.
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Anatomy of the Upper Airway
(1 of 2)
• Divided into upper and lower airways
• Major functions of the upper airway
– Warm, filter, and humidify air brought into the body
• Pharynx
– First portion of the upper airway
– Composed of the nasopharynx and oropharynx
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Anatomy of the Upper Airway
(2 of 2)
• Nasopharynx
– Union of facial bones
– Divided by septum
– Contains the cilia and the turbinates
• Oropharnyx
– Oral cavity; begins with the mouth and teeth
– Tongue, palate, epiglottis, and vallecula
• Larynx
– Complex structure
– Glottic opening is the narrowest portion of the trachea
33
Anatomy of the Lower Airway
• The function of the lower airway is to exchange oxygen
and carbon dioxide.
• Extends from C4 to the xiphoid process (externally);
glottic opening to pulmonary capillary membrane
(internally).
• Inhalation
• Surfactant
• Atelectasis
34
Lung and Respiratory Volumes
•
•
•
•
•
•
•
•
Average adult male total lung capacity is 6 L
Tidal volume (average 5-7 mL/kg)
Dead space
Alveolar air
Minute volume
Functional reserve capacity
Residual volume
Inspiratory/expiratory reserve volumes
35
Ventilation (1 of 2)
• Movement of air into and out of the lungs
• Two phases of ventilation:
– Inspiration
• Stimulus to breathe comes from the respiratory center
located in the medulla
– Expiration
• Stretch receptors in the chest wall and bronchioles send a
signal to the apneustic center to inhibit the inspiratory center
• Hering-Breuer reflex
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Ventilation (2 of 2)
• Respiration is the exchange of gases between a living
organism and its environment.
• Two types of respiration:
– External – exchange of gases between the lungs and
the blood cells
– Internal – exchange of gases between the blood cells
and tissues
37
Causes of Decreased Oxygen
Concentration in the Blood
• Any condition that reduces the surface area for gas
exchange also decreases the oxygen supply
• Pneumothorax
• Decreased mechanical effort
• Medical conditions
– Pulmonary edema
38
Carbon Dioxide in the Blood
• Fluctuates in relation to changes in breathing.
• Hyperventilation rids the body of excessive amounts of
carbon dioxide.
39
The Measurement of Gases
• Dalton’s law of partial pressure
• Total pressure of air (sea level) 760 torr
• Major components
– Nitrogen
– Oxygen
– Carbon dioxide
– Water vapor
40
Respiratory Rate (1 of 2)
• Neural control
– Comes from medulla and pons
– Apneustic center
• Chemical stimuli
– Chemoreceptors monitor the chemical composition of
body fluids
– Hypoxic drive is a “backup system”
41
Respiratory Rate (2 of 2)
• Control of respiration by other factors
– Increase or decrease respirations according to need.
– Certain medications cause the respiratory rate to
increase or decrease.
– Respirations decrease as metabolism slows.
42
Airway Evaluation
• Essential parameters
– Bellows system
– Normal rate: 12-20 breaths/min
• Recognition of airway problems
– Respiratory rate, regularity, or effort
– Look, listen, and feel technique
– History of present illness
– Respiratory pattern changes
43
Acid-Base Balance (1 of 2)
• Defining the acidity of a solution
– Amount of free hydrogen ion
• Ion shifts
– Acid-base balance on both sides of the cell
• Buffers
– Imagined as a bucket
• Circulating bicarbonate buffer
– Holds and neutralizes excess acid
44
Acid-Base Balance (2 of 2)
• Respiratory component
– Fastest way to rid the body of excess hydrogen ions
– Maintaining circulating levels of carbon dioxide in the
blood
• Renal component
– Kidneys respond but take hours to days to restore pH
– Excreting the acid
45
Compensatory Mechanisms
• Acid-base disorders not immediately correctable by the
body’s buffering systems initiate compensatory
mechanisms to help return levels to normal.
46
Clinical Presentation (1 of 2)
• Two types of acid-base disorders
– Metabolic and respiratory
• Respiratory acidosis
– Always related to hypoventilation
• COPD
– Creates respiratory acidosis over time
– Hypoxic drive stimulates breathing based on
circulating oxygen levels in the bloodstream
47
Clinical Presentation (2 of 2)
• Respiratory alkalosis
– Always the result of hyperventilation
• Metabolic acidosis
– Any acidosis not related to the respiratory system
• Metabolic alkalosis
– Results from excessive loss of acid, either from
urination or decreased acid levels in the stomach
48
Maintaining the Airway
• Recovery position
– Helps maintain a clear airway in a patient who has
not had traumatic injuries and is breathing on their
own with a normal rate and adequate tidal volume
– Prevents aspiration of vomitus
49
Airway Management
• Emergency medical care
begins with ensuring a
patient’s airway is open and
breathing is adequate.
• The most common cause of
airway obstruction in an
unresponsive patient is the
tongue.
50
Manual Maneuvers
•
•
•
•
Head tilt-chin lift maneuver
Jaw-thrust maneuver
Jaw-thrust with head tilt
Tongue-jaw lift maneuver
51
Airway Obstructions (1 of 2)
• Tongue
– Falls back without muscle control, creating snoring
respirations
• Foreign body
– Partial or full
• Laryngeal spasm and edema
– Aggressive intubation
52
Airway Obstructions (2 of 2)
• Fractured larynx
– Increases airway resistance
• Aspiration
– Destroys delicate bronchiolar tissue
– Introduces pathogens into the lungs
– Decreases ability to ventilate
53
Recognition
• Early recognition is crucial.
• Good air exchange
– If they can cough forcefully, don’t interfere with their
efforts to expel object on their own
• Poor air exchange
– Weak, ineffective cough
– Treat immediately as if it were a severe air
obstruction
54
Emergency Medical Care for
FBAO
• The Heimlich maneuver is the most effective method of
dislodging an object from the airway.
• Follow the Heimlich maneuver with finger sweeps.
– Attempt to remove the object only if you are able to
visualize and easily retrieve it.
55
Suctioning
• Suctioning equipment
– Portable, hand-operated, oxygen-powered,
battery-operated and fixed (mounted)
• Techniques of suctioning
– Turn on the unit.
– Insert the catheter.
– Open the patient’s mouth.
– Apply suction.
56
Airway Adjuncts
• Oral airway
– Makes suctioning easier
– Should be inserted promptly in unresponsive patients
with no gag reflex
• Nasal airway
– Better tolerated by patients who have an intact gag
reflex
– Use with extreme caution in cases of trauma
57
Oral Airway and Nasal Airway
58
Supplemental Oxygen (1 of 2)
• Oxygen sources
– Supplied as compressed gas in cylinders
– Delivery measured in LPM
• Safety considerations
– Contents under pressure
– Can become a deadly missile
• Liquid oxygen
– Cooled to aqueous state
59
Supplemental Oxygen (2 of 2)
• Pin-indexing system
– Established by the gas industry
– Series of pins on a yoke
• Regulators
– Attached to cylinder stem to deliver gas under high
pressure
• Flowmeters
– Pressure-compensated and Bourdon-gauge
60
Operating Procedures
•
•
•
•
•
Inspect the cylinder.
Attach the regulator/flowmeter.
Place the regulator collar.
Open the cylinder.
Open the flowmeter to desired
rate.
61
Hazards of Oxygen-Delivery
Devices
• Oxygen supports combustion although it doesn’t burn or
explode.
• Be cautious in any enclosed environment because there
is an increased chance of fire if a spark or flame is
introduced.
62
Supplemental Oxygen-Delivery
Devices
•
•
•
•
•
•
•
Non-rebreathing mask
Nasal cannula
Simple face mask
Partial rebreathing mask
Venturi mask
Small-volume nebulizer
Oxygen humidifiers
63
Assisted and Artificial
Ventilation (1 of 2)
• Mouth-to-mouth
– Most basic form of ventilation
– Requires no special equipment
• Mouth-to-nose
• Mouth-to-mask
– Preferred technique over mouth-to-mouth or
mouth-to-nose
– Exhaled air contains roughly 16% oxygen
64
Assisted and Artificial
Ventilation (2 of 2)
• One-person BVM device
– Can provide large volumes of inspired air
– Can deliver nearly 100% oxygen
• Two-person BVM method
– Superior mask seal, tidal volume, and oxygen
delivery
• Three-person BVM method
– Not always possible to perform
65
Two-Person and One-Person
BVM Methods
66
Technique (1 of 2)
•
•
•
•
•
•
•
Kneel above patient’s head.
Maintain neck in an extended position.
Open the mouth.
Select the mask size.
Place mask over face.
Bring lower jaw up to mask.
Hold mask in position.
67
Technique (2 of 2)
• Connect bag to mask.
• Hold mask in place while partner squeezes bag.
• If alone, hold index finger over the lower part of mask,
and secure the upper part with thumb.
• Observe for gastric distention.
68
Flow-Restricted OxygenPowered Ventilation Devices
• FROPVD
– Manually triggered devices
• Components
– Peak flow rate 100%
– Safety release valves
• Automatic transport ventilators
– Same as above but attached to a control box
– Adjustments for rate and volume
69
Gastric Distention
• Occurs when air becomes trapped in the stomach.
• Most likely to occur when patient is ventilated too
forcefully or too often or when the airway is obstructed.
70
Dental Appliances and Facial
Bleeding
• Appliances that become loose should be removed
immediately before attempting ventilation.
– Examples: crown, bridge, dentures
• Facial bleeding
– Injuries to the face can result in bleeding into the
airway.
– Suspect spinal injury.
71
Multilumen Airways (1 of 3)
• Advantages and disadvantages
– Easier insertion
– Can be used only with deeply unresponsive patients
• Indications
– Deeply unresponsive, apneic patients
• Contraindications
– Pediatric patients
– Known pathologic conditions/caustics
72
Multilumen Airways (2 of 2)
• Complications
– Vomiting, hypoventilation, and trauma
• Equipment
– Two tubes and two cuffs
• Procedures before insertion
– Forwardly displace the jaw.
– Insert the device.
– Inflate the cuffs.
73
Multilumen Airways (3 of 3)
• Procedures after insertion
– Begin to ventilate the patient.
– With the PtL, ventilate the short tube.
– With the Combitube, ventilate the long tube.
– Confirm chest rise and breath sounds.
– If none, change to the other inflation port
74
Combitube and PtL
75
Esophageal Obturator Airway
(EOA) (1 of 3)
• Advantages
– Requires less technical skill
• Disadvantages
– Mask seal required to ventilate
• Indications
– Deeply unconscious patients
• Contraindications
– Not for use in patients younger than 16 years
76
Esophageal Obturator Airway
(EOA) (2 of 3)
• Complications
– Hypoventilation, esophageal rupture.
• Equipment
– EOA no longer manufactured.
– EGTA is a modification of the EOA.
• Technique is intended to facilitate entry of the tube into
the esophagus.
77
Esophageal Obturator Airway
(EOA) (3 of 3)
• Procedures before insertion
– All equipment is checked.
– Patient is preoxygenated and positioned.
• Procedures after insertion
– Following inflation of the balloon, obtain a mask seal.
– Confirm presence of breath sounds.
78
Ventilation With an EGTA in
Place
79
The Laryngeal Mask Airway
(1 of 2)
• Advantages
– Insertion is easier and doesn’t require direct laryngoscopy
• Disadvantages
– Increased risk of aspiration and air may be insufflated into the
stomach
• Contraindications
– Use only in “fasting” patients and is less effective in obese
patients
• Complications
– Regurgitation and aspiration
80
The Laryngeal Mask Airway
(2 of 2)
• Technique for insertion
– Prepare equipment
– Inflate with 50% more air than is required
– Deflate it and lubricate the base
– Preoxygenate
– Insert your finger between the cuff and tube
– Insert the LMA and inflate the cuff
• Procedures after insertion
– Ventilate; confirm placement
81
The LMA Device
82
Tracheostomy, Stoma, and
Tracheostomy Tubes
• Tracheostomy – surgical opening into the trachea
• Stoma – the resultant orifice connecting the trachea to
the outside air
• Neither the head tilt-chin lift nor the jaw-thrust maneuver
is required for ventilating a patient with a stoma
• If the patient has a tracheostomy tube, you should
ventilate through the tube with a BVM device
83
Special Patient Considerations
• Laryngectomy suctioning must be performed with
extreme care.
– The slightest irritation of the tracheal wall can result
in a violent laryngospasm.
– To further minimize the risk of complications, limit
suctioning of the stoma to 10 seconds.