Bledsoe et al., Essentials of Paramedic Care: Division 1 2006 by Pearson Education, Inc. Upper...

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Division 1Introduction to Advanced

Prehospital Care

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 8Airway Management

and Ventilation

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Topics

Respiratory ProblemsRespiratory System AssessmentAirway Management

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Respiratory Problems

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Obstruction

The tongue is the most common cause of airway obstruction.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The tongue as an airway obstruction

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Inadequate minute volume respirations can compromise adequate oxygen intake and

carbon dioxide removal.

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Other Causes of Airway Obstruction

Foreign bodiesTraumaLaryngeal spasm and edemaAspiration

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Respiratory System Assessment

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Initial Assessment

Is the airway patent?Is breathing adequate?Look, listen, and feel.If patient is not breathing, open the airway and assist ventilations as necessary.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Feel for air movement.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Look for chest movement.

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Listen for air movement.

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Bag-valve-mask ventilation

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Focused History

OnsetSymptom developmentAssociated symptomsPast medical historyRecent historyDoes anything make symptomsbetter or worse?

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Physical Examination

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Inspection

Skin colorPatient’s positionDyspneaModified forms of respirationRatePatternMentation

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Abnormal Respiratory Patterns (1 of 3)

Kussmaul’s respirations– Deep, slow or rapid, gasping; common in

diabetic ketoacidosis

Cheyne-Stokes respirations– Progressively deeper, faster breathing

alternating gradually with shallow, slower breathing, indicating brain stem injury

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Abnormal Respiratory Patterns (2 of 3)

Biot’s respirations– Irregular pattern of rate and depth with

sudden, periodic episodes of apnea, indicating increased intracranial pressure

Central neurogenic hyperventilation– Deep, rapid respirations, indicating

increased intracranial pressure

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Abnormal Respiratory Patterns (3 of 3)

Agonal respirations– Shallow, slow, or infrequent breathing,

indicating brain anoxia

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Auscultation

Listen at the mouth and nose for adequate air movement.Listen with a stethoscope for normal or abnormal air movement.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Positions for auscultating breath sounds

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Airway SoundsAirflow

CompromiseGas Exchange Compromise

Snoring

Stridor

Wheezing

Quiet

Gurgling

Crackles

Rhonchi

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Palpation

Palpate chest wall for tenderness, symmetry, abnormal motion, crepitus, and subcutaneous emphysema.Assess compliance of lungs.

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Noninvasive Respiratory Monitoring

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Pulse oximeter

© Scott Metcalfe

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Colorimetric End-Tidal CO2 Detector

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Electronic End-Tidal CO2 Detector

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Manual Airway Maneuvers

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Head-tilt/chin-lift

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Modified jaw-thrust in trauma

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Jaw-thrust maneuver

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Jaw-lift maneuver

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Airway before applying Sellick’s

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Sellick’s maneuver(cricoid pressure)

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Airway with Sellick’s applied (note compression on the esophagus)

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Basic Mechanical Airways

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Nasopharyngeal airway

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Nasopharyngeal airway, inserted

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Insert oropharyngeal airway with tip facing palate.

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Rotate airway 180° into position.

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Improper placement of oropharyngeal airway

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Advanced Airway Management

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Endotracheal intubation is clearly the preferred method

of advanced airway management in prehospital emergency care.

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Endotracheal Intubation

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Engaging laryngoscope blade and handle

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Activating laryngoscope light source

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Laryngoscope blades

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Placement of Macintosh blade into vallecula

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Placement of Miller blade under epiglottis

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ETT and syringe

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Endotrol ETT

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ETT, stylet, and syringe, unassembled

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

ETT, stylet, and syringe, assembled for intubation

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Endotracheal Intubation Indicators

Respiratory or cardiac arrestUnconsciousnessRisk of aspirationObstruction due to foreign bodies, trauma, burns, or anaphylaxisRespiratory extremis due to diseasePneumothorax, hemothorax, hemopneumothorax with respiratory difficulty

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Advantages of Endotracheal Intubation

Isolates trachea and permitscomplete control of airwayImpedes gastric distentionEliminates need to maintain a mask sealOffers direct route for suctioningPermits administration of some medications

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Disadvantages of Endotracheal Intubation

Requires considerable training and experienceRequires specialized equipmentRequires direct visualization of vocal cordsBypasses upper airway’s functionsof warming, filtering, and humidifying the inhaled air

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Complications ofEndotracheal Intubation

Equipment malfunctionTeeth breakage and soft tissue lacerationsHypoxiaEsophageal intubationEndobronchial intubationTension pneumothorax

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Personal protective equipment

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hyperventilate patient.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Prepare equipment.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Apply Sellick’s maneuver and insert laryngoscope.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Visualize larynx and insert the ETT.

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Glottis visualized through laryngoscopy

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Inflate cuff, ventilate, and auscultate.

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Confirm placement with an ETCO2 detector.

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Esophageal detector device, bulb style

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

If the bulb does not refill, the tube is improperly placed.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Attach device to endotracheal tube and squeeze the detector.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

If bulb refills easily upon release, it indicates correct placement.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Secure tube.

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Lighted stylet for endotracheal intubation

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Insertion of lighted stylet/ETT

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Lighted stylet/ETT in position

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Transillumination of a lighted stylet

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Blind orotracheal intubation by digital method

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Digital Intubation (1 of 2)

Insert your middle

and index fingers

into patient’s mouth.

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Digital Intubation (2 of 2)

Walk your fingers and palpate the

patient’s epiglottis.

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Digital intubation—insertion of the ETT

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Endotracheal Intubation with In-line Stabilization

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Hyperventilate patient and apply c-spine stabilization.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Apply Sellick’s maneuver and intubate.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Ventilate patient and confirm placement.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Secure ETT and apply a cervical collar.

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Reconfirm placement.

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Rapid Sequence Intubation

A patient who needs intubation may be awake. RSI paralyzes the patient to facilitate endotracheal intubation.

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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Endotracheal Intubation in a Child

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Pediatric Airway

Smaller and more flexible than an adult.Tongue proportionately larger.Epiglottis floppy and round.Glottic opening higher and more anterior.Vocal cords slant upward, and arecloser to the base of the tongue.Narrowest part is the cricoid cartilage.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

ETT size (mm) = (Age in years + 16)

4

Selecting ETT size according to child’s age

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hyperventilate the child.

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Prepare the equipment.

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Insert the laryngoscope.

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Insert ETT and ventilate the child.

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Confirm placement and secure ETT.

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Reconfirm ETT placement.

© Scott Metcalfe

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Ventilation of Pediatric Patients

Mask seal can be more difficult.Bag size depends on age of child.Ventilate according to current standards.Obtain chest rise and fall with each breath.Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Nasotracheal intubation may be useful in some situations:

Possible spinal injuryClenched teethFractured jaw, oral injuries, or recent oral surgeryFacial or airway swellingObesityArthritis preventing sniffing position

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Advantages ofNasotracheal Intubation

The head and neck can remain in neutral position.It does not produce as much gag response and is better tolerated by the awake patient.It can be secured more easily than an orotracheal tube.The patient cannot bite the ETT.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Disadvantages ofNasotracheal Intubation

More difficult and time-consuming to perform than orotracheal intubation.Potentially more traumatic for patients.Tube may kink or clog more easily than an orally placed tube.Poses a greater risk of infection.Improper placement is more likely when performing blind nasotracheal intubation.Blind nasotracheal intubation requires that the patient be breathing.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Blind nasotracheal intubation

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Other Intubation Devices

Esophageal Tracheal CombiTube (ETC)Pharyngo-tracheal Lumen (PtL)Laryngeal Mask Airway (LMA)Intubating Laryngeal Mask Airway (iLMA)Cobra Perilaryngeal Airway (CobraPLA)Ambu Laryngeal Mask (ALM)Esophageal Gastric Tube Airway (EGTA)Esophageal Obturator Airway (EOA)

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ETC airway –esophageal placement

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ETC airway – tracheal placement

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Pharyngo-tracheal lumen airway

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Laryngeal mask airway

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Intubating laryngeal mask airway

LMA North America

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Cobra perilaryngeal airway

Supralaryngeal device designed to be

positioned in the hypopharynx where it abuts the structure of

the laryngeal inlet

Engineered Medical Systems, Inc.

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Ambu laryngeal mask

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Continuously recheck and reconfirm the placement of

the endotracheal tube.

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Foreign body removal with direct visualization and Magill forceps

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Magill forceps

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The only indication for a surgical airway is

the inability to establish an airway by any other method.

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Direct visualization of the larynx with a laryngoscope may enable the removal

of an obstructing foreign body.

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Anatomical landmarksfor cricothyrotomy

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Locate/palpate cricothyroid membrane.

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Proper positioning for cricothyroid puncture

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Advance the catheter with the needle.

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Cannula properly placed in trachea

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Jet ventilation withneedle cricothyrotomy

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Open Cricothyrotomy

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Locate cricothyroid membrane.

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Stabilize larynx and make a 1–2 cm skin incision over cricothyroid membrane.

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Make a 1 cm horizontal incision through the cricothyroid membrane.

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Using a curved hemostat, spread membrane incision open.

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Insert an ETT (6.0) or Shiley (6.0).

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Inflate the cuff.

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Confirm placement.

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Ventilate.

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Secure tube, reconfirm placement, evaluate patient.

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Tracheostomy cannulae

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Patients with Stoma Sites

Patients who have had a laryngectomy or tracheostomy breathe through a stoma.There are often problems with excess secretions, and a stoma may become plugged.

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Suctioning

Anticipating complications when managing an airway is the key for successful outcomes. – Be prepared to suction all airways to

remove blood or other secretions and forthe patient to vomit.

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Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Suctioning Techniques

Wear protective eyewear, gloves, and face mask.Preoxygenate the patient.Determine depth of catheter insertion.With suction off, insert catheter.Turn on suction and suction whileremoving catheter (no more than10 seconds).Hyperventilate the patient.

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Tracheostomy suction technique

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Gastric Decompression (1 of 3)

Common problem with ventilating a nonintubated patient is gastric distention.Occurs when the procedure’s high pressures trap air in the stomach.Once patient has gastric distention, you should place a tube in the stomach for gastric decompression, using either the nasogastric or orogastric approach.

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Gastric Decompression (2 of 3)

To place a nasogastric or orogastric tube:Prepare patient’s head in neutral position while preoxygenating.Determine length of tube insertion by measuring from the epigastrium to the angle of the jaw, then to the tip of the nares.If patient is awake, suppress the gag reflex with a topical anesthetic applied into the posterior oropharynx or with IV lidocaine.

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Gastric Decompression (3 of 3)

Lubricate the distal tip of the gastric tube and gently insert into the nares and along the nasal floor, or into the oral cavity at midline. Advance tube gently, and if patient is awake, encourage swallowing to facilitate tube’s passage.Advance to predetermined mark on tube.Confirm placement.Apply suction and note gastric contents that pass through the tube.Secure the tube in place.

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Oxygenation

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Never withholdoxygen fromany patient for whom it is indicated!

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To calculate how long an oxygen tank will last:

D cylinder tank life in minutes = (tank pressure in psi × 0.16) ÷ liters per minute

E cylinder tank life in minutes = (tank pressure in psi × 0.28) ÷ liters per minute

M cylinder tank life in minutes = (tank pressure in psi × 1.56) ÷ liters per minute

Oxygen Supply and Regulators

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Oxygen Delivery Devices

Device Oxygen Percentage

Nasal cannula

Simple face mask

Nonrebreather mask

Venturi mask

40%

24, 28, 35, or 40%

40 – 60%

80 – 95%

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Ventilation Methods

Mouth-to-mouthMouth-to-noseMouth-to-maskBag-valve deviceDemand valve deviceAutomatic transport ventilator

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Bag-valve mask with built-in colorimetric

ETCO2 detector

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Ventilation of Pediatric Patients

Mask seal can be more difficult.Bag size depends on age of child.Ventilate according to current standards.Obtain chest rise and fall witheach breath.Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement.

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Demand valve and mask

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Portable mechanical ventilator

Bledsoe et al., Essentials of Paramedic Care: Division 1© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary

Respiratory ProblemsRespiratory System AssessmentAirway Management