United States Department of Transportation

National Highway Traffic Safety Administration

Paramedic: National Standard Curriculum

(Reprinted with permission)

http://www.nhtsa.dot.gov/people/injury/ems/

Airway: 2

Airway Management: 1

UNIT TERMINAL OBJECTIVE

2-1 At the completion of this unit, the paramedic student will be able to establish and/ or maintain a patent airway, oxygenate, and ventilate a patient.

COGNITIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

2-1.1 Explain the primary objective of airway maintenance. (C-1)

2-1.2 Identify commonly neglected prehospital skills related to airway. (C-1)

2-1.3 Identify the anatomy of the upper and lower airway. (C-1)

2-1.4 Describe the functions of the upper and lower airway. (C-1)

2-1.5 Explain the differences between adult and pediatric airway anatomy. (C-1)

2-1.6 Define gag reflex. (C-1)

2-1.7 Explain the relationship between pulmonary circulation and respiration. (C-3)

2-1.8 List the concentration of gases that comprise atmospheric air. (C-1)

2-1.9 Describe the measurement of oxygen in the blood. (C-1)

2-1.10 Describe the measurement of carbon dioxide in the blood. (C-1)

2-1.11 Describe peak expiratory flow. (C-1)

2-1.12 List factors that cause decreased oxygen concentrations in the blood. (C-1)

2-1.13 List the factors that increase and decrease carbon dioxide production in the body. (C-1)

2-1.14 Define atelectasis. (C-1)

2-1.15 Define FiO₂. (C-1)

2-1.16 Define and differentiate between hypoxia and hypoxemia. (C-1)

2-1.17 Describe the voluntary and involuntary regulation of respiration. (C-1)

2-1.18 Describe the modified forms of respiration. (C-1)

2-1.19 Define normal respiratory rates and tidal volumes for the adult, child, and infant. (C-1)

2-1.20 List the factors that affect respiratory rate and depth. (C-1)

2-1.21 Explain the risk of infection to EMS providers associated with ventilation. (C-3)

2-1.22 Define pulsus paradoxes. (C-1)

2-1.23 Define and explain the implications of partial airway obstruction with good and poor air exchange. (C-1)

2-1.24 Define complete airway obstruction. (C-1)

2-1.25 Describe causes of upper airway obstruction. (C-1)

2-1.26 Describe causes of respiratory distress. (C-1)

2-1.27 Describe manual airway maneuvers. (C-1)

2-1.28 Describe the Sellick (cricoid pressure) maneuver. (C-1)

2-1.29 Describe complete airway obstruction maneuvers. (C-1)

2-1.30 Explain the purpose for suctioning the upper airway. (C-1)

2-1.31 Identify types of suction equipment. (C-1)

2-1.32 Describe the indications for suctioning the upper airway. (C-3)

2-1.33 Identify types of suction catheters, including hard or rigid catheters and soft catheters. (C-1)

2-1.34 Identify techniques of suctioning the upper airway. (C-1)

2-1.35 Identify special considerations of suctioning the upper airway. (C-1)

2-1.36 Describe the indications, contraindications, advantages, disadvantages, complications, equipment and technique of tracheobronchial suctioning in the intubated patient. (C-3)

2-1.37 Describe the use of an oral and nasal airway. (C-1)

2-1.38 Identify special considerations of tracheobronchial suctioning in the intubated patient. (C-1)

2-1.39 Define gastric distention. (C-1)

2-1.40 Describe the indications, contraindications, advantages, disadvantages, complications, equipment and technique for inserting a nasogastric tube and orogastric tube. (C-1)

2-1.41 Identify special considerations of gastric decompression. (C-1)

2-1.42 Describe the indications, contraindications, advantages, disadvantages, complications, and technique for inserting an oropharyngeal and nasopharyngeal airway (C-1)

2-1.43 Describe the indications, contraindications, advantages, disadvantages, complications, and technique for ventilating a patient by: (C-1)

1. Mouth-to-mouth

2. Mouth-to-nose

3. Mouth-to-mask

4. One person bag-valve-mask

5. Two person bag-valve-mask

6. Three person bag-valve-mask

7. Flow-restricted, oxygen-powered ventilation device

2-1.44 Explain the advantage of the two person method when ventilating with the bag-valve-mask. (C-1)

2-1.45 Compare the ventilation techniques used for an adult patient to those used for pediatric patients. (C-3)

2-1.46 Describe indications, contraindications, advantages, disadvantages, complications, and technique for ventilating a patient with an automatic transport ventilator (ATV). (C-1)

2-1.47 Explain safety considerations of oxygen storage and delivery. (C-1)

2-1.48 Identify types of oxygen cylinders and pressure regulators (including a high-pressure regulator and a therapy regulator). (C-1)

2-1.49 List the steps for delivering oxygen from a cylinder and regulator. (C-1)

2-1.50 Describe the use, advantages and disadvantages of an oxygen humidifier. (C-1)

2-1.51 Describe the indications, contraindications, advantages, disadvantages, complications, liter flow range, and concentration of delivered oxygen for supplemental oxygen delivery devices. (C-3)

2-1.52 Define, identify and describe a tracheostomy, stoma, and tracheostomy tube. (C-1)

2-1.53 Define, identify, and describe a laryngectomy. (C-1)

2-1.54 Define how to ventilate with a patient with a stoma, including mouth-to-stoma and bag-valve-mask-to-stoma ventilation. (C-1)

2-1.55 Describe the special considerations in airway management and ventilation for patients with facial injuries. (C-1)

2-1.56 Describe the special considerations in airway management and ventilation for the pediatric patient. (C-1)

2-1.57 Differentiate endotracheal intubation from other methods of advanced airway management. (C-3)

2-1.58 Describe the indications, contraindications, advantages, disadvantages and complications of endotracheal intubation. (C-1)

2-1.59 Describe laryngoscopy for the removal of a foreign body airway obstruction. (C-1)

2-1.60 Describe the indications, contraindications, advantages, disadvantages, complications, equipment, and technique for direct laryngoscopy. (C-1)

2-1.61 Describe visual landmarks for direct laryngoscopy. (C-1)

2-1.62 Describe use of cricoid pressure during intubation. (C-1)

2-1.63 Describe indications, contraindications, advantages, disadvantages, complications, equipment and technique for digital endotracheal intubation. (C-1)

2-1.64 Describe the indications, contraindications, advantages, disadvantages, complications, equipment and technique for using a dual lumen airway. (C-3)

2-1.65 Describe the indications, contraindications, advantages, disadvantages, complications and equipment for rapid sequence intubation with neuromuscular blockade. (C-1)

2-1.66 Identify neuromuscular blocking drugs and other agents used in rapid sequence intubation. (C-1)

2-1.67 Describe the indications, contraindications, advantages, disadvantages, complications and equipment for sedation during intubation. (C-1)

2-1.68 Identify sedative agents used in airway management. (C-1)

2-1.69 Describe the indications, contraindications, advantages, disadvantages, complications, equipment and technique for nasotracheal intubation. (C-1)

2-1.70 Describe the indications, contraindications, advantages, disadvantages and complications for performing an open crichothyrotomy. (C-3)

2-1.71 Describe the equipment and technique for performing an open cricothyrotomy. (C-1)

2-1.72 Describe the indications, contraindications, advantages, disadvantages, complications, equipment and technique for transtlaryngeal catheter ventilation (needle cricothyrotomy). (C-3)

2-1.73 Describe methods of assessment for confirming correct placement of an endotracheal tube. (C-1)

2-1.74 Describe methods for securing an endotracheal tube. (C-1)

2-1.75 Describe the indications, contraindications, advantages, disadvantages, complications, equipment and technique for extubation. (C-1)

2-1.76 Describe methods of endotracheal intubation in the pediatric patient. (C-1)

AFFECTIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

2-1.77 Defend the need to oxygenate and ventilate a patient. (A-1)

2-1.78 Defend the necessity of establishing and/ or maintaining patency of a patient’s airway. (A-1)

2-1.79 Comply with standard precautions to defend against infectious and communicable diseases. (A-1)

PSYCHOMOTOR OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

2-1.80 Perform body substance isolation (BSI) procedures during basic airway management, advanced airway management, and ventilation. (P-2)

2-1.81 Perform pulse oximetry. (P-2)

2-1.82 Perform end-tidal CO₂ detection. (P-2)

2-1.83 Perform peak expiratory flow testing. (P-2)

2-1.84 Perform manual airway maneuvers, including: (P-2)

a. Opening the mouth

b. Head-tilt/ chin-lift maneuver

c. Jaw-thrust without head-tilt maneuver

d. Modified jaw-thrust maneuver

2-1.85 Perform manual airway maneuvers for pediatric patients, including: (P-2)

a. Opening the mouth

b. Head-tilt/ chin-lift maneuver

c. Jaw-thrust without head-tilt maneuver

d. Modified jaw-thrust maneuver

2-1.86 Perform the Sellick maneuver (cricoid pressure). (P-2)

2-1.87 Perform complete airway obstruction maneuvers, including: (P-2)

a. Heimlich maneuver

8. Finger sweep

9. Chest thrusts

10. Removal with Magill forceps

2-1.88 Demonstrate suctioning the upper airway by selecting a suction device, catheter and technique. (P-2)

2-1.89 Perform tracheobronchial suctioning in the intubated patient by selecting a suction device, catheter and technique. (P-2)

2-1.90 Demonstrate insertion of a nasogastric tube. (P-2)

2-1.91 Demonstrate insertion of an orogastric tube. (P-2)

2-1.92 Perform gastric decompression by selecting a suction device, catheter and technique. (P-2)

2-1.93 Demonstrate insertion of an oropharyngeal airway. (P-2)

2-1.94 Demonstrate insertion of a nasopharyngeal airway. (P-2)

2-1.95 Demonstrate ventilating a patient by the following techniques: (P-2)

a. Mouth-to-mask ventilation

11. One person bag-valve-mask

12. Two person bag-valve-mask

13. Three person bag-valve-mask

14. Flow-restricted, oxygen-powered ventilation device

15. Automatic transport ventilator

16. Mouth-to-stoma

17. Bag-valve-mask-to-stoma ventilation

2-1.96 Ventilate a pediatric patient using the one and two person techniques. (P-2)

2-1.97 Perform ventilation with a bag-valve-mask with an in-line small-volume nebulizer. (P-2)

2-1.98 Perform oxygen delivery from a cylinder and regulator with an oxygen delivery device. (P-2)

2-1.99 Perform oxygen delivery with an oxygen humidifier. (P-2)

2-1.100 Deliver supplemental oxygen to a breathing patient using the following devices: nasal cannula, simple face mask, partial rebreather mask, non-rebreather mask, and venturi mask (P-2)

2-1.101 Perform stoma suctioning. (P-2)

2-1.102 Perform retrieval of foreign bodies from the upper airway. (P-2)

2-1.103 Perform assessment to confirm correct placement of the endotracheal tube. (P-2)

2-1.104 Intubate the trachea by the following methods: (P-2)

a. Orotracheal intubation

b. Nasotracheal intubation

c. Multi-lumen airways

18. Digital intubation

d. Transillumination

e. Open cricothyrotomy

2-1.105 Adequately secure an endotracheal tube. (P-1)

2-1.106 Perform endotracheal intubation in the pediatric patient. (P-2)

2-1.107 Perform transtracheal catheter ventilation (needle cricothyrotomy). (P-2)

2-1.108 Perform extubation. (P-2)

2-1.109 Perform replacement of a tracheostomy tube through a stoma. (P-2)

DECLARATIVE

I. Introduction

1. The body’s need for oxygen

2. Primary objective of emergency care

a. Ensure optimal ventilation

(1) Delivery of oxygen

(2) Elimination of CO₂

3. Brain death occurs within 6 to 10 minutes

4. Major prehospital causes of preventable death

a. Early detection

b. Early intervention

c. Lay-person BLS education

5. Most often neglected of prehospital skills

a. Basics taken for granted

b. Poor techniques

(1) BVM seal

(2) Improper positioning

(3) Failure to reassess

II. Anatomy of upper airway

1. Function of the upper airway

a. Warm

b. Filter

c. Humidify

2. Pharynx

a. Nasopharynx

(1) Formed by the union of facial bones

(2) Orientation of nasal floor is towards the ear not the eye

(3) Separated by septum

(4) Lined with

(a) Mucous membranes

(b) Cilia

(5) Turbinate

(a) Parallel to nasal floor

(b) Provide increased surface area for air

i) Filtration

ii) Humidifying

iii) Warming

(6) Sinuses

(a) Cavities formed by cranial bones

(b) Appear to further trap bacteria and act as tributaries for fluid to and from Eustachian tubes and tear ducts

i) Commonly become infected

ii) Fracture of certain sinus bones may cause cerebrospinal fluid (CSF) leak

(7) Tissues extremely delicate and vascular

(a) Improper or overly aggressive placement of tubes or airways will cause significant bleeding which may not be controlled by direct pressure

b. Oropharynx

(1) Teeth

(a) 32 adult

(b) Requires significant force to dislodge

(c) May fracture or avulse causing obstruction

(2) Tongue

(a) Large muscle attached at the mandible and hyoid bones

(b) Most common airway obstruction

(3) Palate

(a) Roof of mouth separates oro/ nasopharynx

i) Anterior is hard palate

ii) Posterior (beyond the teeth) is soft palate

(4) Adenoids

(a) Lymph tissue located in the mouth and nose that filters bacteria

(b) Frequently infected and swollen

(5) Posterior tongue

(6) Epiglottis

(7) Vallecula

(a) "Pocket" formed by the base of the tongue and epiglottis

(b) Important landmark for endotracheal intubation

3. Larynx

a. Attached to hyoid bone

(1) "Horseshoe-shaped” bone between the chin and mandibular angle

(2) Supports trachea

(3) Made of cartilage

b. Thyroid cartilage

(1) First tracheal cartilage

(2) "Shield-shaped"

(a) Cartilage anterior

(b) Smooth muscle posterior

(3) Laryngeal prominence

(a) "Adam's Apple" anterior prominence of thyroid cartilage

(b) Glottic opening directly behind

c. Glottic opening

(1) Narrowest part of adult trachea

(2) Patency heavily dependent on muscle tone

(3) Contain vocal bands

(a) White bands of cartilage

(b) Produce voice

d. Arytenoid cartilage

(1) "Pyramid-like" posterior attachment of vocal bands

(2) Important landmark for endotracheal intubation

e. Pyriform fossae

(1) “Hollow pockets” along the lateral borders of the larynx

f. Cricoid ring

(1) First tracheal ring

(2) Completely cartilaginous

(3) Compression occludes esophagus (Sellick maneuver)

g. Cricothyroid membrane

(1) Fibrous membrane between cricoid and thyroid cartilage

(2) Site for surgical and alternative airway placement

h. Associated structures

(1) Thyroid gland

(a) Located below cricoid cartilage

(b) Lies across trachea and up both sides

(2) Carotid arteries

(a) Branches cross and lie closely alongside trachea

(3) Jugular veins

(a) Branch across and lie close to trachea

III. Anatomy of lower airway

1. Function of the lower airway

a. Exchange of O₂ and CO₂

2. Location of the lower airway

a. From fourth cervical vertebrae to xiphoid process

b. From glottic opening to pulmonary capillary membrane

3. Structures of the lower airway

a. Trachea

(1) Trachea bifurcates at carina into

(a) Right and left mainstem bronchi

(b) Right mainstem has lesser angle

i) Foreign bodies, ET tubes commonly displace here

(2) Lined with

(a) Mucous cells

(b) Beta 2 receptors - dilate bronchioles

b. Bronchi

(1) Mainstem bronchi enter lungs at hilum

(2) Branch into narrowing secondary and tertiary bronchi that branch into bronchioles

c. Bronchioles

(1) Branch into alveolar ducts that end at alveolar sacs

d. Alveoli

(1) "Balloon-like” clusters

(2) Site of gas exchange

(3) Lined with surfactant

(a) Decreases surface tension of alveoli which facilitates ease of expansion

(b) Alveoli become thinner as they expand which makes diffusion of O₂/ CO₂ easier

(c) If surfactant is decreased or alveoli are not inflated, alveoli collapse (atelectasis)

e. Lungs

(1) Right lung

(a) 3 lobes

(2) Left lung

(a) 2 lobes

(3) Lobes made of parenchymal tissue

(4) Membranous outer lining called pleura

(5) Lung capacity

IV. Differences in pediatric airway

1 Pharynx

a0 A proportionately smaller jaw causes the tongue to encroach upon the airway

b0 Omega shaped, floppy epiglottis

c0 Absent or very delicate dentition

2 Trachea

a0 Airway is smaller and narrower at all levels

b0 Larynx lies more superior

c0 Larynx is "funnel-shaped" due to narrow, undeveloped cricoid cartilage

d0 Narrowest point is at cricoid ring before 10 years of age

e0 Further narrowing of the airway by tissue swelling of foreign body results in major increase in airway resistance

3 Chest wall

a0 Ribs and cartilage are softer

b0 Cannot optimally contribute to lung expansion

c0 Infants and children tend to depend more heavily on the diaphragm for breathing

V Lung/ respiratory volumes

1 Total lung volume

a0 Adult male, 6 liters

b0 Not all inspired air enters alveoli

c0 Minor diffusion of O₂ takes place in alveolar ducts and terminal bronchioles

2 Tidal volume

a0 Volume of gas inhaled or exhaled during a single respiratory cycle

b0 5-7cc/ kg (500 cc normally)

3 Dead space air

a0 Air remaining in air passageways, unavailable for gas exchange (approximately 150cc)

b0 Anatomic dead space

(1) Trachea

(2) Bronchi

c0 Physiologic dead space

(1) Dead space formed by factors like disease or obstruction

(a) COPD

(b) Atelectasis

4 Minute volume

a0 Amount of gas moved in and out of the respiratory tract per minute

b0 Determined by

(1) Tidal volume - dead space volume times respiratory rate

5 Functional reserve capacity

a0 After optimal inspiration: optimum amount of air that can be forced from the lungs in a single exhalation

6 Residual volume

a0 Volume of air remaining in lungs at the end of maximal expiration

7 Alveolar air

a0 Air reaching the alveoli for gas exchange (alveolar volume)

b0 Approximately 350 cc

8 Inspiratory reserve

a0 Amount of gas that can be inspired in addition to tidal volume

9 Expiratory reserve

a0 Amount of gas that can be expired after a passive (relaxed) expiration

10 FiO₂

a0 Percentage of oxygen in inspired air (increases with supplemental oxygen)

(1) Commonly documented as a decimal (e.g., FiO₂ = .85)

VI Ventilation

1 Definition - movement of air into and out of the lungs

2 Phases

a0 Inspiration

(1) Stimulus to breathe from respiratory center

(2) Impulse transmitted to diaphragm via phrenic nerve

(a) Diaphragm - "muscle of respiration"

(b) Separates thoracic from abdominal cavity

(3) Diaphragm contracts - "flattens"

(a) Causes intrapulmonic pressure to fall slightly below atmospheric pressure

(4) Intercostal muscles contract

(5) Ribs elevate and expand

(6) Air is drawn into lungs like a vacuum

(7) Alveoli Inflate

(8) O₂/ CO₂ are able to diffuse across membrane

b0 Expiration

(1) Stretch receptors in lungs signal respiratory center via vagus nerve to inhibit inspiration (Hering-Breuer Reflex)

(2) Natural elasticity (recoil) of the lungs passively expires air

VII Respiration

1 Definition

a0 Exchange of gases between a living organism and its environment

b0 The major gases of respiration are oxygen and carbon dioxide

2 Types

a0 External respiration - exchange of gasses between the lungs and the blood cells

b0 Internal respiration - exchange of gases between the blood cells and tissues

3 The transportation of oxygen and carbon dioxide in the human body

a0 Diffusion - passage of solution from area of higher concentration to lower concentration

(1) O₂/ CO₂ dissolve in water and pass through alveolar membrane by diffusion

b0 Oxygen content of blood

(1) Dissolved O₂ crosses pulmonary capillary membrane and binds to hemoglobin (Hgb) of red blood cell

(2) Oxygen is carried

(a) Bound to hemoglobin

(b) Dissolved in plasma

(3) Approximately 97% of total O₂ is bound to hemoglobin

(4) O₂ saturation

(a) % of hemoglobin saturated

(b) Normally greater than 98%

c0 Oxygen in the blood

(1) Bound to hemoglobin

(a) SaO₂

(2) Dissolved in plasma

(a) PaO₂

d0 Carbon dioxide content of the blood

(1) CO₂ is a byproduct of cellular work (cellular respiration)

(2) CO₂ is transported in blood as bicarbonate ion

(3) About 33% is bound to hemoglobin

(4) As O₂ crosses into blood, CO₂ diffuses into alveoli

(5) Carbon dioxide in the blood

(a) PaCO₂

e0 Diagnostic testing

(1) Pulse oximetry

(2) Peak expiratory flow testing

(3) End-tidal CO₂ monitoring

(4) Other equipment

VIII Causes of decreased oxygen concentrations in the blood

1 Lower partial pressure of atmospheric O₂

2 Lower hemoglobin levels in blood

3 Trauma

a0 Less surface area for gas exchange

(1) Pneumothorax

(2) Hemothorax

(3) Combination of pneumothorax and hemothorax

b0 Decreased mechanical effort

(1) Pain

(2) Traumatic suffocation

(3) Hypoventilation

4 Medical

a0 Physiological barriers

(1) Pneumonia

(2) Pulmonary edema

(3) COPD

IX Carbon dioxide in blood

1 Increases

a0 Hypoventilation

2 Decreases

a0 Hyperventilation

X The measurement of gases

1 Total pressure

a0 The combined pressure of all atmospheric gases

b0 100% or 760 torr at sea level

2 Partial pressure

a0 The pressure exerted by a specific atmospheric gas

3 Concentration of gases in the atmosphere

a0 Nitrogen 597.0 torr (78.62%)

b0 Oxygen 159.0 torr (20.84%)

c0 CO₂ 0.3 torr ( 0.04%)

d0 Water 3.7 torr ( 0.5%)

4 Water vapor pressure

5 Alveolar gas concentration

a0 Nitrogen 569.0 torr (74.9%)

b0 Oxygen 104.0 torr (13.7%)

c0 CO₂ 40.0 torr ( 5.2%)

d0 Water 47.0 torr ( 6.2%)

XI Respiratory rate

1 Definition - the number of times a person breathes in one minute

2 Neural control

a0 Primary control from the medulla and pons

b0 Medulla

(1) Primary involuntary respiratory center

(2) Connected to respiratory muscles by vagus nerve

c0 Pons

(1) Apneustic center - secondary control center if medulla fails to initiate respiration

(2) Pneumotaxic center - controls expiration

3 Chemical stimuli

a0 Receptors for O₂/ CO₂ balance

(1) Cerebrospinal fluid pH

(2) Carotid bodies (sinus)

(3) Aortic arch

b0 Hypoxic drive - respiratory stimulus dependent on O₂ rather than CO₂ in the blood

4 Control of respiration by other factors

a0 Body temperature - respirations increase with fever

b0 Drug and medications - may increase or decrease respirations depending on their physiologic action

c0 Pain - increases respirations

d0 Emotion - increases respirations

e0 Hypoxia - increases respirations

f0 Acidosis - respirations increase as compensatory response to increased CO₂ production

g0 Sleep - respirations decrease

XII Pathophysiology

1 Obstruction

a0 Tongue

(1) Most common airway obstruction

(2) Snoring respirations

(3) Corrected with positioning

b0 Foreign body

(1) May cause partial or full obstruction

(2) Symptoms include

(a) Choking

(b) Gagging

(c) Stridor

(d) Dyspnea

(e) Aphonia (unable to speak)

(f) Dysphonia (difficulty speaking)

c0 Laryngeal spasm and edema

(1) Spasm

(a) Spasmotic closure of vocal cords

(b) Most frequently caused by

i Trauma from over aggressive technique during intubation

ii Immediately upon extubation especially when patient is semiconscious

(2) Edema

(a) Glottic opening becomes extremely narrow or totally obstructed

(b) Most frequently caused by

i Epiglottitis (a bacterial infection of the epiglottis)

ii Anaphylaxis (severe allergic reaction)

iii Relieved by

(c) Aggressive ventilation

(d) Forceful upward pull of the jaw

(e) Muscle relaxants

d0 Fractured larynx

(1) Airway patency dependent upon muscle tone

(2) Fractured laryngeal tissue

(a) Increases airway resistance by decreasing airway size through

i Decreasing muscle tone

ii Laryngeal edema

iii Ventilatory effort

e0 Aspiration

(1) Significantly increases mortality

(a) Obstructs airway

(b) Destroys delicate bronchiolar tissue

(c) Introduces pathogens

(d) Decreases ability to ventilate

XIII Airway evaluation

1 Essential parameters

a0 Rate

(1) Normal resting rate in adults - 12-24

b0 Regularity

(1) Steady pattern

(2) Irregular respiratory patterns are significant until proven otherwise

c0 Effort

(1) Breathing at rest should be effortless

(2) Effort changes may be subtle in rate or regularity

(3) Patients often compensate by preferential positioning

i Upright sniffing

ii Semifowlers

iii Frequently avoid supine

2 Recognition of airway problems

a0 Respiratory distress

(1) Upper and lower airway obstruction

(2) Inadequate ventilation

(3) Impairment of the respiratory muscles

(4) Impairment of the nervous system

b0 Difficulty in rate, regularity, or effort is defined as dyspnea

c0 Dyspnea may be result of or result in hypoxia

(1) Hypoxia - lack of oxygen

(2) Hypoxia - lack of oxygen to tissues

(3) Anoxia - total absence of oxygen

d0 Recognition and treatment of dyspnea is crucial to patient survival

(1) Expert assessment and management is essential

(a) The brain can survive only a few minutes of anoxia

(b) All therapies fail if airway is inadequate

e0 Visual techniques

(1) Position

(a) Tripod positioning

(b) Orthopnea

(2) Rise and fall of chest

(3) Gasping

(4) Color of skin

(5) Flaring of nares

(6) Pursed lips

(7) Retraction

(a) Intercostal

(b) Suprasternal notch

(c) Supraclavicular fossa

(d) Subcostal

f0 Auscultation techniques

(1) Air movement at mouth and nose

(2) Bilateral lung fields equal

g0 Palpation Techniques

(1) Air movement at mouth and nose

(2) Chest wall

(a) Paradoxical motion

(b) Retractions

h0 Bag-valve-mask

(1) Resistance or changing compliance with bag-valve-mask ventilations

i0 Pulsus paradoxus

(1) Systolic blood pressure drops greater than 10mm Hg with inspiration

(a) Change in pulse quality maybe detected

(b) Seen in COPD, pericardial tamponade

(c) Possible increase in intrathoracic pressure

j0 History

(1) Evolution

(a) Sudden

(b) Gradual over time

(c) Known cause or "trigger"

(2) Duration

(a) Constant

(b) Recurrent

(3) Ease - what makes it better?

(4) Exacerbate - what makes it worse?

(5) Associate

(a) Other symptoms (productive cough, chest pain, fever, etc...)

(6) Interventions

(a) Evaluations/ admissions to hospital

(b) Medications (include compliance)

(c) Ever intubated

k0 Modified forms of respiration

(1) Protective reflexes

(a) Cough

i Forceful, spastic exhalation

ii Aids in clearing bronchi and bronchioles

(b) Sneeze - clears nasopharynx

(c) Gag reflex - spastic pharyngeal and esophageal reflex from stimulus of the posterior pharynx

(2) Sighing

(a) Involuntary deep breath that increases opening of alveoli

(b) Normally sigh about once per minute

(3) Hiccough - intermittent spastic closure of glottis

l0 Respiratory pattern changes

(1) Cheyne-Stokes

(a) Gradually increasing rate and tidal volume followed by gradual decrease

(b) Associated with brain stem insult

(2) Kussmaul’s breathing

(a) Deep, gasping respirations

(b) Common in diabetic coma

(3) Biot’s respirations

(a) Irregular pattern, rate, and volume with intermittent periods of apnea

(b) Increased intracranial pressure

(4) Central neurogenic hyperventilation

(a) Deep rapid respirations similar to Kussmall's

(b) Increased intracranial pressure

(5) Agonal

(a) Slow, shallow, irregular respirations

(b) Resulting from brain anoxia

m0 Inadequate ventilation

(1) Occurs when body cannot compensate for increased O₂ demand or maintain O₂/ CO₂ balance

(2) Many causes

(a) Infection

(b) Trauma

(c) Brainstem insult

(d) Noxious or hypoxic atmosphere

(e) Renal failure

(3) Multiple symptoms

(a) Altered response

(b) Respiratory rate changes (up or down)

XIV Supplemental oxygen therapy

1 Rationale

a0 Enriched O₂ atmosphere increases oxygen to cells

b0 Increasing available O₂ increases patient's ability to compensate

c0 O₂ delivery method must be reassessed to determine adequacy and efficiency

2 Oxygen source

a0 Compressed gas

(1) Oxygen compressed in gas form in an aluminum or steel tank

(2) Common sizes and volumes

(a) D 400L

(b) E 660L

(c) M 3450L

(3) O₂ delivery measured in liters/ min (LPM)

(4) Calculating tank life

(a) Tank pressure (psi) x 0.28 = volume

(b) Volume/ LPM = tank life in minutes

b0 Liquid oxygen

(1) O₂ cooled to its aqueous state

(a) Converts to gaseous state when warmed

(2) Advantage

(a) Much larger volume of gaseous O₂ can be stored in aqueous state

(3) Disadvantage

(a) Units generally require upright storage

(b) Special requirements for large volume storage and cylinder transfer

3 Regulators

a0 High-pressure

(1) Attached to cylinder stem delivers cylinder gas under high pressure

(2) Used to transfer cylinder gas from tank to tank

b0 Therapy regulators

(1) Attached to cylinder stem

(2) 50psi escape pressure is "stepped down" through regulator mechanism

(3) Subsequent delivery to patient is adjustable low pressure

4 Delivery devices

a0 Nasal cannula

(1) Nasally placed O₂ catheter for oxygen enrichment

(2) Optimal delivery: 40% at 6 L/ min

(3) Indications

(a) Low to moderate O₂ enrichment

(b) Long term O₂ maintenance therapy

(4) Contraindications

(a) Poor respiratory effort

(b) Severe hypoxia

(c) Apnea

(d) Mouth breathing

(5) Advantages

(a) Well tolerated

(6) Disadvantages

(a) Does not deliver high volume/ high concentration

b0 Simple face mask

(1) Full airway enclosure with open side ports

(a) Room air is drawn through side ports on inspiration

(b) Diluting O₂ concentration

(2 Indications

(a Delivery of moderate to high O₂ concentrations

(b Range - 40-60% at 10 L/ min

(3 Advantages

(a Higher O₂ concentrations

(4 Disadvantages

(a Delivery of volumes beyond 10 L/ min does not enhance O₂ concentration

(5 Special considerations

(a Mask leak around face decreases O₂ concentration

c. Partial rebreather

(1 Mask vent ports covered by one-way disc

(a Residual expired air mixed in mask and rebreathed

(b Room air not entrained with inspiration

(2 Indications

(3 Contraindications

(a Apnea

(b Poor respiratory effort

(4 Advantages

(a Inspired gas not mixed with room air

i) Higher O₂ concentrations attainable

(b Disadvantages

i) Delivery of volumes beyond 10 L/ min does not enhance O₂ concentration

(c Special considerations

i) Mask leak around face decreases O₂ concentration

d. Non-rebreather mask

(1 Mask side ports covered by one-way disc

(2 Reservoir bag attached

(3 Range: 80-95+% at 15 L/ min

(4 Indications

(a Delivery of highest O₂ concentration

(5 Contraindications

(a Apnea

(b Poor respiratory effort

(6 Advantages

(a Highest O₂ concentration

(b Delivers high volume/ high O₂ enrichment

(c Patient inhales enriched O₂ from reservoir bag rather than residual air

(7 Disadvantages

e. Venturi mask

(1 Mask with interchangeable adapters

(a Adapters have port holes that entrain room air as O₂ passes

(b Patient receives a highly specific concentration of O₂

(c Air is entrained by venturi principle

f. Small volume nebulizer

(1 Delivers aerosolized medication

(2 O₂ enters an aerosol chamber containing 3-5 ccs of fluid

(3 Pressurized O₂ mists fluid

5. Oxygen humidifiers

a. Sterile water reservoir for humidifying O₂

b. Good for long term O₂ administration

c. Desirable for croup/ Epiglottitis/ bronchiolitis

6. Tracheostomy, stoma, and tracheostomy tubes

a. Tracheostomy

(1 Surgical opening into trachea

(a Done in operating room under controlled conditions

(b A stoma located just superior to the suprasternal notch

b. Stoma

(1 Resultant orifice connecting trachea to outside air

(2 Patient now breathes through this surgical opening

c. Tracheostomy tube

(1 Plastic tube placed within tracheostomy site

(2 15 mm connector for ventilator acceptance

XV. Ventilation

1. Mouth-to-mouth

a. Most basic form of ventilation

b. Indications

(1 Apnea from any mechanism when other ventilation devices are not available

c. Contraindications

(1 Awake patients

(2 Communicable disease risk limitations

d. Advantages

(1 No special equipment required

(2 Delivers excellent tidal volume

(3 Delivers adequate oxygen

e. Disadvantages

(1 Psychological barriers from

(a Sanitary issues

(b Communicable disease issues

i) Direct blood/ body fluid contact

ii) Unknown communicable disease risks at time of event

f. Complications

(1 Hyperinflation of patient's lungs

(2 Gastric distension

(3 Blood/ body fluid contact manifestation

(4 Hyperventilation of rescuer

2. Mouth-to-nose

a. Ventilating through nose rather than mouth

b. Indications

(1 Apnea from any mechanism

c. Contraindications

(1 Awake patients

d. Advantages

(1 No special equipment required

e. Disadvantages

(1 Direct blood/ body fluid contact

(2 Psychological limitations of rescuer

f. Complications

(1 Hyperinflation of patient's lungs

(2 Gastric distension

(3 Blood/ body fluid manifestation

(4 Hyperventilation of rescuer

3. Mouth-to-mask

a. Adjunct to mouth-to-mouth ventilation

b. Indications

(1 Apnea from any mechanism

c. Contraindications

(1 Awake patients

d. Advantages

(1 Physical barrier between rescuer and patient blood/ body fluids

(2 One-way valve to prevent blood/ body fluid splash to rescuer

(3 May be easier to obtain face seal

e. Disadvantages

(1 Useful only if readily available

f. Complications

(1 Hyperinflation of patient's lungs

(2 Hyperventilation of rescuer

(3 Gastric distention

g. Method for use

(1 Position head by appropriate method

(2 Position and seal mask over mouth and nose

(3 Ventilate as appropriate

4. One person bag-valve-mask

a. Fixed volume self inflating bag can deliver adequate tidal volumes and O₂ enrichment

b. Indications

(1 Apnea from any mechanism

(2 Unsatisfactory respiratory effort

c. Contraindications

(1 Awake, intolerant patients

d. Advantages

(1 Excellent blood/ body fluid barrier

(2 Good tidal volumes

(3 Oxygen enrichment

(4 Rescuer can ventilate for extended periods without fatigue

e. Disadvantages

(1 Difficult skill to master

(2 Mask seal may be difficult to obtain and maintain

(3 Tidal volume delivered is dependent on mask seal integrity

f. Complications

(1 Inadequate tidal volume delivery with

(a Poor technique

(b Poor mask seal

(c Gastric distention

g. Method for use

(1 Position appropriately

(2 Choose proper mask size - seats from bridge of nose to chin

(3 Position, spread/ mold/ seal mask

(4 Hold mask in place

(5 Squeeze bag completely over 1.5 to 2 seconds for adults

(6 Avoid overinflation

(7 Reinflate completely over several seconds

h. Special considerations

(1 Medical

(a Observe for

i) Gastric distension

ii) Changes in compliance of bag with ventilation

iii) Improvement or deterioration of ventilation status ( i.e., color change, responsiveness, air leak around mask)

(2 Trauma

(a Very difficult to perform with cervical spine immobilization in place

5. Two person bag-valve-mask ventilation method

a. Most efficient method

b. Indications

(1 Bag-valve-mask ventilation on any patient

(a Especially useful for cervical spine immobilized patients

(b Difficulty obtaining or maintaining adequate mask seal

c. Contraindications

(1 Awake, intolerant patients

d. Advantages

(1 Superior mask seal

(2 Superior volume delivery

e. Disadvantages

(1 Requires extra personnel

f. Complications

(1 Hyperinflation of patient's lungs

(2 Gastric distension

g. Method for use

(1 First rescuer maintains mask seal by appropriate method

(2 Second rescuer squeezes bag

h. Special considerations

(1 Observe chest movement

(2 Avoid overinflation

(3 Monitor lung compliance with ventilations

6. Three person bag-valve-mask ventilation

a. Indications

(1 Bag-valve-mask ventilation on any patient

(a Especially useful for cervical spine immobilized patients

(b Difficulty obtaining or maintaining adequate mask seal

b. Contraindications

(1 Awake, intolerant patients

c. Advantages

(1 Superior mask seal

(2 Superior volume density

d. Disadvantages

(1 Requires extra personnel

(2 “Crowded” around airway

e. Complications

(1 Hyperinflation of patient’s lungs

(2 Gastric distension

f. Method for use

(1 First rescuer maintains mask seal by appropriate method

(2 Second rescuer holds mask in place

(3 Third rescuer squeezes bag and monitors compliance

g. Special considerations

(1 Avoid overinflation

(2 Monitor lung compliance with ventilations

7. Flow-restricted, oxygen-powered ventilation devices

a. The valve opening pressure at the cardiac sphincter is approx 30 cm H₂O

b. These devices operate at or below 30 cm H₂O to prevent gastric distension

c. Indications

(1 Delivery of high volume/ high concentration of O₂ (1 L/ sec)

(2 Awake compliant patients

(3 Unconscious patient with caution

d. Contraindications

(1 Noncompliant patients

(2 Poor tidal volume

(3 Small children

e. Advantages

(1 Self administered

(2 Delivers high volume/ high concentration O₂

(3 O₂ delivered in response to inspiratory effort (no O₂ wasting)

(4 O₂ volume delivery is regulated by inspiratory effort minimizing overinflation risk

(5 O₂ volume delivery is also restricted to less than 30 cm H₂O

f. Disadvantages

(1 Cannot monitor lung compliance

(2 Requires O₂ source

g. Complications

(1 Gastric distension

(2 Barotrauma

h. Method

(1 Mask is held manually in place

(2 Negative pressure upon inspiration triggers O₂ delivery or medic triggers release button

(3 Patient is monitored for adequate tidal volume and oxygenation

8. Automatic transport ventilators

a. Volume/ rate controlled

b. Indications

(1 Extended ventilation of intubated patients

(2 In situations in which a BVM is used

(3 Can be used during CPR

c. Contraindications

(1 Awake patients

(2 Obstructed airway

(3 Increased airway resistance

(a Pneumothorax (after needle decompression)

(b Asthma

(c Pulmonary edema